| Title | State |
Last Updated |
| Irrevocable Letter Of Credit |
South Dakota | April 13, 2015 |
| Dispute Resolution Form (Intracorp) |
South Dakota | April 13, 2015 |
| Dispute Resolution Form (Genex Care For South Dakota) |
South Dakota | April 13, 2015 |
| Petition To Controvert |
Mississippi | April 13, 2015 |
| Answer |
Mississippi | April 13, 2015 |
| Employers Application For Privilege Of Paying Compensation As Self Insurer |
Mississippi | April 13, 2015 |
| Petition for Benefit Determination |
Tennessee | February 27, 2015 |
| Claim For Medical Services |
Maryland | February 4, 2015 |
| Claim For Medical Services |
Maryland | February 4, 2015 |
| Employers Application For Permission To Carry Risk Without Insurance (For New And Renewal Applicants) |
Indiana | January 21, 2015 |
| Claimants Consent To Pay Attorney And Doctor Fees |
Maryland | January 13, 2015 |
| Agreement On The Propriety Of Services And Selection Of Practitioner |
Maryland | January 12, 2015 |
| Attending Doctors Request For Authorization And Carriers Response |
New York | December 23, 2014 |
| Inspection Form |
Connecticut | December 23, 2014 |
| Employer Participation Form |
Connecticut | December 23, 2014 |
| Utilization Review Company Minimum Standards |
Connecticut | December 23, 2014 |
| Request To Enter Appearance Of Counsel |
Maryland | October 14, 2014 |
| Cover Sheet-Rebuttal Of Application For Full Board Review |
New York | October 7, 2014 |
| Request For Travel Reimbursement |
Texas | September 29, 2014 |
| Medical Treatment Provider List |
Utah | September 5, 2014 |
| Notice Of Discontinuance Of Form I-18 - Election Of Non Coverage By Subcontractor |
Tennessee | September 2, 2014 |
| Vocational Assessment |
Kansas | August 6, 2014 |
| Vocation Rehabilitation Closure Report |
Kansas | August 6, 2014 |
| Vendors Request For Additional Expeditures |
Kansas | August 6, 2014 |
| Vendor Referral For |
Kansas | August 6, 2014 |
| Report Of Fraud Or Abuse (Confidential) |
Kansas | August 6, 2014 |
| Rehabilitation Vendor Progress Report |
Kansas | August 6, 2014 |
| Rehabilitation Plan |
Kansas | August 6, 2014 |
| Registration For Access To Electronic Records |
Kansas | August 6, 2014 |
| Qualified Rehabilitation Professional Application |
Kansas | August 6, 2014 |
| Plan Amendment |
Kansas | August 6, 2014 |
| Order For Production Of Records |
Kansas | August 6, 2014 |
| Medical Management Closure Report |
Kansas | August 6, 2014 |
| IAM Crest Vendor Referral Report |
Kansas | August 6, 2014 |
| Affidavit Attesting To The Use Of Public Records (KSA 45-230) |
Kansas | August 6, 2014 |
| Independent Examiners Report Of Request For Information Or Response To Request Regarding Ind Med Exam |
New York | August 5, 2014 |
| Rights And Responsibilities |
Kansas | August 1, 2014 |
| Request For Workers Compensation Records |
Kansas | August 1, 2014 |
| Order On Joint Petition And Stipulation For Reimbursement From WC Fund |
Kansas | August 1, 2014 |
| Employers Report Of Accident |
Kansas | August 1, 2014 |
| Joint Petition And Stipulation For Reimbursement From WC Fund |
Kansas | August 1, 2014 |
| Joint Petition And Stipulation |
Kansas | August 1, 2014 |
| Award On Joint Petition-Stipulation For Structured Settlement Or Annuity |
Kansas | August 1, 2014 |
| Award On Joint Petition And Stipulation |
Kansas | August 1, 2014 |
| Carriers Request For Reimbursement Of Compensation Payments Under Section 14(6) (Blue Paper) |
New York | July 21, 2014 |
| Accident Prevention Services Annual Report w-Intsructions |
Texas | February 5, 2014 |
| Accident Prevention Services Worksheet |
Texas | February 5, 2014 |
| Workers Compensation Coverage Waiver |
Utah | February 4, 2014 |
| HBA Participation Agreement |
Utah | February 4, 2014 |
| Petition For Reimbursement From The Employers Reinsurance Fund |
Utah | February 4, 2014 |
